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Chapter

Psychosomatic Pain
Ertuğrul Allahverdi

Abstract

Disorders that are not clearly attributable to an organic disease are called
somatoform disorders. Their symptoms are called psychosomatic symptoms and
include insomnia, fatigue, and weakness. These disorders can also be associated with
heartburn, depression, irregular heartbeat, dizziness, pain, cardiovascular prob-
lems, gastrointestinal discomfort, erectile dysfunction, a sensation of pressure in
the throat, chest problems, hallucinations, and double vision. Somatoform disorders
can be an expression of untreated mental pain and life experiences, resulting from
serious loss, profound personal injury, or disrespect. Such symptoms occur in almost
all humans, but these disorders can have a serious effect in 4–20% of the population.

Keywords: psychosomatic, pain, chronic pain, stress

1. Introduction

Psychosomatic pain: “A combination of symptoms of physical pain in various

body areas that occur during any life period, where treatment is sought for the pain
by going to many health clinics, and resulting in disruption of social and/or occupa-
tional activities” [1–3].
“Soma” means the body. “Psychosomatic” diseases in psychiatry are mainly
due to psychological causes that are not based on an organic etiology or physical
disorders.
It is currently believed that conscious or unconscious emotions, thoughts, and
behaviors are also effective in psychosomatic disease in biological organisms and
should be evaluated together with the dual thoughts related to the body and mind
status. The patient may use more atypical and exaggerated expressive words from
time to time when defining psychogenic pain. The localization and periodicity of
the patient’s pain can also be persistently atypical. The pain of the patient usually
begins after some important life events and stresses. The emotional burden of the
factors stimulating and triggering pain is reflected in the patient’s voluntary pos-
ture and the relevant muscle groups. A psychological dimension, depression and
anxiety are usually noted among the accompanying symptoms. It is noteworthy
that the characteristics of the pain do not conform to anatomical facts and physi-
ological functioning. Besides, the response to analgesics is also often atypical.
Accompanying symptoms such as anger, impatience, helplessness, boredom, and
restlessness must be considered in patients with psychological pain.
Both psychosocial and biological factors always play a role in the development
and pathophysiological mechanism of psychogenic pain [1–4].
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) reference
book of diagnostic criteria in psychiatry explains psychosomatic diseases as fol-
lows [1–3]:

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Effects of Stress on Human Health

“A combination of multiple physical symptoms that occur within a period of time,

with continuing search for treatment, and resulting in deterioration of social or
professional life.”

The following criteria must be present to make a diagnosis of a psychosomatic

disorder according to the DSM-IV:

• Having at least four separate pains (headache, abdominal pain, pain in the arms
and legs, back pain, etc.)

• Two gastrointestinal tract symptoms (nausea, bloating, vomiting without preg-

nancy, diarrhea, gastric irritation)

• One sexual function or genital system symptom (menstrual irregularity, impo-

tence in men, sexual aversion to women and men, etc.)

• One neurological symptom (impaired balance, regional paralysis or decreased

strength, difficulty swallowing, double vision, deafness, loss of consciousness,
etc.)

• Lack of an organic disorder to explain these symptoms as a result of medical exami-

nation, laboratory investigations, and imaging methods

• No addiction to alcohol, drugs, or other substances

• Insecure and skeptical approach to psychiatric examination

• Stress is one of the major causes of psychosomatic diseases. Stress causes many
bodily functions to deteriorate or not work properly.

• The most common trigger of psychosomatic diseases is loss and separation.

The American Board of Medical Specialties and the American Psychiatry and
Neurology Board have approved specialization in psychosomatic medicine in 2003.
This decision has emphasized the importance of this field and also reintroduced the
widespread use of the “psychosomatic” term [1–3].
The Diagnostic Criteria for Psychosomatic Research (DCPR) are considered to
be more explanatory than the DSM-IV [1–3].

2. DCPR definition criteria

Persistent somatization subjects with a psychosomatic disorder are believed to

have a higher incidence of other nonfunctional system (chronic fatigue) syndromes
in the future with this approach, and these are called “multisomatoform disorder,”
“pure somatization,” or “chronic somatization.” The functional somatic symptoms
secondary to a psychiatric disorder are as follows:

a. Conversion symptoms

b. Anniversary reaction: the anniversary reaction defines the somatic, emo-

tional, and behavioral responses at the anniversary of the period where a loss
has been suffered.

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2.1 Abnormal behavior

a. Health anxiety: the health anxiety concept includes many different types of
beliefs and fears related to illness and pain.

b. Fear of illness: fear of illness is the unsupported and persistent fear that a
specific illness (such as AIDS or cancer) is present despite examination results
and assurances to be contrary, as defined in the DCPR.

c. Denial of illness: the denial concept as specified in psychoanalytic theory is

an ego defense mechanism against unpleasant thoughts. Denial has later been
included in the emotion-focused coping strategies when faced with stressful
conditions.

d.Fear of death (thanatophobia): this is a sudden feeling or belief that the sub-
ject is about to die despite the lack of a medical reason. It must not be confused
with the fear of unavoidable death.

3. The psychological aspect of disease: psychological factors influencing

medical conditions

Demoralization (lack of resistance): hopelessness is the most important

aspect. There is a loss of the feeling of usefulness/effectiveness. Mood reactivity is
usually preserved.
Alexithymia: alexithymia is a personality type that is characterized by difficulty
in recognizing emotions, difficulty communicating, and a cognitive structure and
operative thought that focuses on external focus and external center adaptation.
Type A behavior: Type A behavior leads to taking care of more work in con-
tinually shorter times. Coronary disorders are more common in these subjects. They
have irritable mood and are impatient and agitated.
Irritable mood: irritable mood is characterized by decreased anger control and
usually results in verbal or behavioral bursts of anger.
It is important to have knowledge about the pain and its variety before psychoso-
matic pain, because pain can cause psychosomatic problems as well as result.
Pain is thought to be an important clinical and socioeconomic problem all
around the world. We investigated the incidence, prevalence, and economic burden
of pain conditions in children, adolescents, and adults based on the electronic
scanning of databases for articles published between 2000 and 2014 in this review.
Differences in methodology and the epidemiological studies make it difficult to give
precise predictions of prevalence and incidence; however, the economic burden of
psychosomatic pain is clearly high. There is a need to develop concepts and methods
to examine pain from a population perspective and to advance the development
of pain prevention and management strategies. Family physicians and clinicians
have great responsibilities in the diagnosis and treatment of pain and especially
psychosomatic pain within this context. The participation of physicians in multidis-
ciplinary training and studies is also a fundamental principle [3, 5].
It is appropriate to explain psychosomatic pain primarily in accordance with
general principles. Pain is a defining characteristic in the diagnosis of many
diseases. It can serve as an index of the symptoms and activity of the disease or
diseases and as a prognostic indicator and a predictor of the use of health care for
the underlying etiology [1, 2]. The International Association for the Study of Pain
(IASP) and the World Health Organization (WHO) describe pain as “an unpleasant

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sensory and emotional experience associated with or described in relation to real

or potential tissue damage or associated with such damage,” “an unpleasant sensory
and emotional experience associated with existing or possible tissue damage or
associated with such damage,” and “a protection mechanism” [2].
An overview of the epidemiology and economic burden of pain conditions in
children, adolescents, and adults is summarized below under the relevant headings.
The incidence and prevalence of pain conditions as well as the risk factors and the
effect of pain on individuals have also been described. The wide range of pain con-
ditions in clinical and research areas include pain in children and adolescents, spinal
pain, neuropathic pain, musculoskeletal pain, and fibromyalgia/chronic diffuse
pain. In addition to the factors associated with the prevalence of pain, the indi-
vidual, economic, and social burden of pain conditions should also be considered.

4. Classification of pain

1. According to neurophysiological mechanisms

a. Nociceptive

b. Somatic

c. Visceral

d.Neuropathic (non-nociceptive) central or peripheral

e. Psychogenic

2. According to the duration

a. Acute

b. Chronic

3. According to the etiologic factors

a. Cancer pain

b. Postherpetic neuralgia

c. Pain due to sickle cell anemia

d.Arthritis pain

4. According to the pain region

a. Headache

b. Facial pain

c. Low back pain

d.Pelvic pain

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Before making a diagnosis of psychogenic pain, somatic pathology must be

definitely eliminated. A diagnostic nerve block can be used for the diagnosis, and
psychological or psychiatric conditions should be evaluated as a factor in pain etiol-
ogy using the criteria in the DSM-IV and DCPR classifications. One must know the
general pain definitions, classifications, and criteria well to be able act objectively
when dealing with the diagnosis and criteria of psychosomatic pain. Psychosomatic
pain is often found in the etiology together with the definitions provided below
[1–3, 5].

5. Pain incidence and definition

Describing the epidemiology of pain is difficult because of the subjective nature

of symptoms and the lack of consensus on the definitions of specific diagnoses and
conditions. It is problematic to identify pain areas, especially with musculoskeletal
pain. Many pain conditions are episodic, and the majority of patients express recur-
rent symptoms at varying intervals and durations during periods with and without
pain. The actual incidence of most pain conditions may therefore remain unknown.
Similarly, study results vary due to differences in the identification of diffuse
pain cases and the specific diagnosis. While case definitions may also vary depend-
ing on the duration, intensity, or psychological burden of pain in the patient, the
diagnoses are based on subjective patient experience, clinical tests, or results of
imaging and pathological studies. It may be difficult to compare studies reporting
different periods of prevalence (e.g., timepoint, weekly, monthly, lifetime) [5].

6. The incidence and distribution of pain

6.1 Pain in children and adolescents

Pain conditions in children and adolescents have gradually become the focus of
the scientific literature in recent years. The occurrence of pain in children evidence
as indicates childhood or adolescence pain can predict adulthood pain. Children
with pain discontinue their education or become withdrawn. Physical inactivity is a
possible result. Low back pain, headache, and abdominal pain are the most common
types of childhood and adolescence pain.
The reported 1-year incidence of low back pain in children and adolescents
varies from 11.8 to 33.0% (median, 22.4%), while the 1-month prevalence varies
from 9.8 to 36.0% (median, 22.9%). Since there are a lower number of studies on
the prevalence of neck pain (49.0%) and upper back pain (30.0%), some doubt
remains about the accuracy of these predictions. A systematic review of chronic
pain epidemiology in children and adolescents (pain continuing for more than
3 months) has reported that the 1-month prevalence of chronic back pain was
between 18.0 and 24.0% (median, 21.0%) [6–9]. In addition to these predic-
tions obtained from systematic reviews, the 1-month prevalence of low back pain
was reported to be 37.0% in more than 400,000 children and adolescents aged
11–15 years [10–14].
The predicted 1-month headache prevalence in children and adolescents is 26.0–
69.0% (median, 47.5%) in systematic investigations. Swain et al. have reported this
figure to be 54.1% in a survey based on 312 schools [15]. Recurrent abdominal pain
(at least three episodes that limit the child’s functions for at least 3 months) is the
focus of most childhood and adolescence pain studies [16]. Recurrent abdominal
pain prevalence has been reported as 0.3–19.0% (median, 8.4%) [17] and 3.8–41.2%

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Effects of Stress on Human Health

(median, 12.0%) [7]. Childhood and adolescence monthly multiple pain prevalence
was 12.1–35.7% (median, 23.9%).
Further studies on pain epidemiology in children and adolescents are still
required to evaluate the effect of age on the pain prevalence. The effects of
the increased pain rates in childhood and adolescence and of the transition to
adolescence on the incidence and prevalence of pain conditions are not clear at
present [17].

6.2 Spinal pain

Spinal pain, and especially low back pain, is a common problem that most
people experience at a certain point in their lives. The lifetime prevalence of low
back pain is reported to be between 51.0 and 84.0%. There are many studies on the
epidemiology of low back pain compared to other pain conditions.
Predictions for the 1-year first low back pain events varied between 6.3 and
15.4% (median, 10.9%) in one review [18] and between 13.5 and 26.2% (median,
19.9%) in others [11, 16, 18–22]. Predictions of the 1-year incidence of low back
pain events (including patients with previous episodes) vary between 1.5 and 38.9%
(median, 20.2%). Many people who experience activity-limiting low back pain
recover quickly [23], but some have recurrent pains [24]. Predictions for the 1-year
recurrence vary between 24.0 and 80.0% (median, 52.0%) [18].
Important information is present on the prevalence of low back pain. The
1-month prevalence is predicted to be between 24.0 and 49.5% (median, 36.8%)
[25]. The prevalence of thoracic spine pain varies between 1.4 and 34.8% (median,
18.1%) [26], while the 1-month prevalence of neck pain varies between 15.4 and
45.3% (median, 30.4%) [27].
Chronic low back pain (CLBP) is usually defined as low back pain continuing for
more than 12 weeks [28]. The prevalence of CLBP in the general European popula-
tion has been predicted as 5.9–18.1% (median, 12%).

6.3 Neuropathic pain and sciatica

Neuropathic pain has been defined by the International Association for the
Study of Pain as “pain caused by a lesion or disease of the somatosensory nervous
system” [29]. It is differentiated from other inflammatory conditions by character-
istic signs and symptoms such as “burning” or “freezing,” numbness, tingling, or
“pins and needles” sensations [29]. There are only a few studies on the incidence
and prevalence of neuropathic pain in the population.
Chronic pain with neuropathic features has a prevalence of 0.9–17.9%
(median, 9.4%) [13]. Prevalence in cancer is 19.0–39.1% (median, 29.1%) [14]. The
incidence is 3.9–42.0 per postherpetic neuralgia, 12.6–28.9 for trigeminal neuralgia,
0.2–0.4 for glossopharyngeal neuralgia, and 15.3–72.3 for painful diabetic periph-
eral neuropathy, respectively, all per 100.000 person years [13].
Sciatica is also called radiculopathy, nerve root compression-irritation, nerve
root pain, or lumbosacral radicular syndrome [30]. The pain is believed to arise in
the lumbar spine but is felt in the leg pain by the patline. The 1-year sciatica inci-
dence is reported as 9.3% [30]. The 1-month sciatica prevalence varies between 0.4
and 16.4% (median, 8.4%) [31].

6.4 Musculoskeletal pain

Musculoskeletal system disorders are among the most common causes of dis-
ability and incapacity, especially in the elderly [32]. Upper extremity pain is also

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common; monthly shoulder pain symptoms are present in 18.6–31.0% (median,

24.8%) of adults [33]. Monthly knee pain prevalence in adults is 13.0–28.0%
(median, 20.5%) [34]. The prevalence was 28.0, 15.0, and 14.0% for foot ankle and
toe pain in a review combining the reported figures [35].

6.5 Fibromyalgia and chronic diffuse pain

Chronic diffuse pain is defined as the presence of chronic pain with diffuse
localization [36]. The American College of Rheumatology defines chronic diffuse
pain as bilateral axial skeleton pain continuing for 3 months or more in its 1990
guidelines [37]. Fibromyalgia diagnostic criteria have been defined using the same
definition [38]. Some fibromyalgia prevalence figures are 2.0–5.0% in the USA,
0.7% in Denmark, and 10.5% in Norwegian women. Fibromyalgia is a clinical
diagnosis similar to other chronic pain conditions, and the lack of a clear definition
therefore limits the comparison of prevalence predictions. The diagnostic criteria
for fibromyalgia in the American College of Rheumatology’s 2010 Criteria include
the evaluation of diffuse pain together with the other symptoms (such as fatigue
and cognitive symptoms) to develop a more specific case definition [38]. Future
studies on the epidemiology of fibromyalgia are likely to increase the accuracy of
current prevalence predictions by using this definition [39].

7. Prevalence tendencies over time

Only a few studies have evaluated the prevalence of pain conditions, and most
have focused on the prevalence of low back pain. Palmer et al. [40] reported that
the 1-year prevalence of low back pain increased by 12.7% over a 10-year period
from 1987 to 1997, and this increase was associated with gender, age group, social
class, and residence area. A contrasting decrease in the 1-month prevalence from
26.1 to 22.6% has been reported over a 7-year period in another study [41]. The
chronic low back pain frequency In the USA has increased from 3.9 in 1992 to 10.2%
in 2006 [42].

8. The effects of pain on health

Pain, and especially chronic pain, creates a significant burden for patients
and their families. It adversely affects the general health perception, significantly
inhibits daily activities, is associated with depressive symptoms, and significantly
and negatively affects the relationships and interactions with others. The World
Health Organization Global Burden of Disease uses the term “disability” to assess
the potential for non-mortality-related disease. They define disability as any
short- or long-term loss of health [43]. Disability-adjusted life years (DALYs) and
years lived with disability (YLDs) are needed to measure and compare the limita-
tions of a wide range of disorders associated with pain. Pain-related disorders that
are characterized or defined by the presence of pain (low back pain, neck pain,
other musculoskeletal disorders, migraine, and falls) constitute 5 of the top 10
conditions responsible for YLDs in the world. Acute low back pain has caused 83
million DALYs, and according to the effects of the chronic types of back pain, this
constitutes 10.7% of all YLDs [43]. Neck pain and migraine/headache each account
for about 24 million DALYs. Other musculoskeletal disorders are responsible for 28
million DALYs and traumas due to falls for 19 million DALYs. Other important con-
tributions include osteoarthritis (17 million DALYs) and accident-related injuries

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Effects of Stress on Human Health

(13 million DALYs) [44]. These results for 1990 and 2010 supersede all previously
published Global Burden of Disease results.

9. Risk factors for pain

It is difficult to determine the factors initiating pain episodes in the population

as studies only specify an estimate due to the differences in the methodology and
reporting. It is necessary to focus on the main risk categories such as age, gender,
social group, and individual factors. Generally, there is no evidence for the risk
factors of pain. Future studies that evaluate all aspects of the pain experience from
both the individual and the population point of view are needed. These studies
must employ multidimensional methods in the case of psychosomatic pain.

10. Age and gender

Studies on pain in children and adolescents have shown that females generally
suffer more pain than males. The relationship between pain and gender is clear in
adults. Females report more severe pain, more frequent pain, and longer-lasting
pain than males in most studies. However, it is not known whether this gender
difference is due to underlying biological pain mechanisms or the effects of psycho-
logical and social factors.
As regards age, the prevalence of some pain disorders such as back pain increases
from childhood to adolescence. The effect of age is not relevant on the pain preva-
lence in the elderly as some studies report that it increases, while others report it
decreases with age. The effect also varies by gender and the pain location [41]. It is
believed that musculoskeletal pain is most common in adults in the employment age
and the prevalence therefore decreases from the middle of the sixth decade [41].
However, recent studies have shown that pain continues to be a widespread and
serious problem in the elderly. The prevalence of chronic pain in the active elderly
(>65 years) varies between 25.0 and 76.0%, while it is much higher in the sedentary
elderly at between 83.0 and 93.0% [41].

11. Social factors

The role of social factors continuously increases throughout life [45]. The
socioeconomic status is usually measured by the complex created by education,
income, and occupation. Many studies in children and adolescents have evaluated
the relationship between pain and socioeconomic status, but there is some evidence
of a conflict between these studies [7]. An inverse relationship is present between
the socioeconomic status and pain prevalence in adults. The data show that lower
educational status, low income, and being unemployed are related to increased pain
prevalence [5].
More recently, pain prevalence studies have been conducted in populations of
various cultural, ethnic, and socioeconomic statuses. Native Americans, Alaska
Natives, and Aboriginal Canadians have been found to have a higher prevalence
of pain than the general population of the United States [45]. Studies in Africa
have found the 1-year prevalence of pain to be 33.0% in adolescents and 50.0%
in adults [46]. This value is higher than reported in studies conducted in most
Western countries (mean prevalence of 38.1%) [25]. However, it is difficult to make
a definite comparison due to the differences in methodology. Another study based

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on the World Bank Human Development Index has reported the prevalence of
chronic pain to be 24.8% in less developed countries and 28.1% in more developed
countries [47].

12. Individual factors

Various individual risk factors have been associated with the development of
pain disorders. The demands of employment, lack of job security, an immobile
job position, dissatisfaction with work, low levels of social support at work, and
vibrating bodily work conditions have been associated with various occupational
factors that lead to musculoskeletal pain. Individual lifestyle factors that create
health problems such as smoking and obesity can also play a role in the develop-
ment of pain disorders [34]. The psychosocial variables believed to influence the
pain prevalence include stress, anxiety, lack of sleep, depression, low self-confi-
dence, and the presence of chronic health problems (irregular heartbeat, dizziness,
pain, cardiovascular problems, gastrointestinal discomfort, erectile dysfunction,
feeling of lump or pressure in the throat, chest problems, hallucinations, and
double vision).
Pain and disorders that are not clearly attributable to an organic disease are
called somatoform disorders. These disorders can be an expression of untreated
mental pain and life experiences resulting from serious loss, profound personal
injury, and disrespect. These symptoms occur in almost all humans, but they can
become a serious problem in 4–20% of the population [1–3, 5–9, 48].
Genetic research on pain is increasing, and chronic pain is being seen as a classic
example of the gene–environment interaction [49]. It is generally believed that the
first trigger of chronic pain syndromes are inflammatory processes or nerve trauma.
Once chronic pain develops, the pain intensity and response to analgesics are also
quite variable. However, evidence is lacking regarding the influence of genetic
effects and the interaction with psychosocial environmental factors as regards
the development of chronic pain. Patients with chronic pain feel that the cause is
life challenges, but the disease also makes life more difficult. This contradictory
approach is related to the importance attributed to the pain. A person with intra-
psychic conflict may not have to express the problem verbally and may have to use
the organs to do so (alexithymia).
The presence of enhancers in the environment: one example is caring for one’s
wife when she has pain but not caring when she does not. Other examples are as
follows: finding comfort by suffering pain for a bad action; excessive interest in pain
and then relaxing when the test results are normal (somatization); and feeling sure
an illness is present and changing physicians frequently (hypochondriasis).
Type A persons (hasty, impatient, hyperactive) perceive pain more easily
than type B persons (calm, cool), probably due to autonomic hyperactivity. The
risk of hypertension and coronary heart disease is 3–5 times higher in type A
persons [50, 51].

13. The financial effects of pain

13.1 Total cost

The cumulative cost of chronic pain to the patient, the health-care system, and
the economy is huge. In Australia, with a population of 22.7 million, the total annual
cost of chronic pain was estimated as 34.3 billion dollars in 2007 or 10.847 dollars

9
Effects of Stress on Human Health

per person [52]. The total cost in Europe is estimated as 1.5–3.0% of the European
GDP [53]. In the USA, approximately 100 million adults have been affected by
chronic pain in 2008, including joint pain and arthritis [54]. The total cost in 2010
was 560–635 billion dollars. The annual cost of pain is higher than that of heart
disease (309 billion dollars), cancer (243 billion dollars), and diabetes (188 billion
dollars) [53, 55–60].
The term psychosomatic means the person. It combines two basic components,
including the mind and the body. The reason is that physical complaints are at the
forefront. However the research will investigate if there are any physical symptoms
to explain such bodily complaints.
There is no medical illness, and this is a definable psychiatric disorder.

14. Examples of psychological problems seen with psychosomatic pain

disorders

1. Somatoform disorders: (a) somatization disorder, (b) conversion disorder,

(c) pain disorder, (d) hypochondriasis, and (e) body dysmorphic disorder

2. Mood disorders: (a) generalized anxiety disorder (objective anxiety, neurotic

anxiety, or traumatic anxiety and moral anxiety), b) panic disorder, (c) agora-
phobia, (d) dysthymic disorder, and (e) major depressive disorder

Pain experts still do not know whether pain is one of the senses or an experience.
The fact that pain can be learned and that it can be affected by beliefs, expectations,
and emotional states is quite important in its diagnosis and treatment. It is known
that psychological disorders increase pain, while extreme fear, stress, and shock
decrease pain. Many studies have reported that cultural norms and expectations
play a major role in feeling pain and the related behavior.
The gate control system that monitors pain is especially influenced by neurotrans-
mitter modulation that is associated with cortical stimulants in anxious subjects. The
lack of an adequate 5-hydroxyl tryptamine (5HT) level in the synapse disturbs pain
perception and decreases the pain threshold and pain tolerance [50, 51].
The physical and psychological problems of the person described under the
following titles also play a role in psychosomatic pain.
Emotional crises. Emotional crises and chronic distress can lead to various
psychosomatic complaints. The whole organism can be affected and the effects are
therefore not listed here.
Somatoform pain disorder. Somatoform pain disorder is characterized by
intense and agonizing pain that is subjectively felt in a part of the body for at
least 6 months and that cannot be reasonably explained by a physical disorder or
physiological event. The onset of the pain is related to a significant problem that
has created serious emotional and/or psychosocial stress, conflict, or trauma. The
increased interest in the person and the medical care received are the possible
gains from the disorder. When compared with somatization disorders, these pains
are long-lasting, and the patient focuses on them. The differential diagnosis of
pain syndromes requires differentiation of organic physical pain from histrionic
processing.
Dissociative disorder. The absence or modification of physical functions
without a physical cause is usually the result of an intrapsychic conflict and can
lead to psychogenic paralysis, coordination disorders, tremors, and myoclonus
(muscle twitching).

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Major depression. Major depression affects the entire body including the
metabolism and the musculoskeletal system. Inactivity or pain syndromes may be
present. The pain, lack of exercise, social withdrawal, smoking habits, and malnu-
trition lead to significant difficulties in the patient’s life.
The patient comes to the doctor because of the somatic complaints as he/she has
usually not noticed the depression: it is therefore not an independent disease. It is
possible to determine the real psychic etiology during the examination if retrospec-
tive evaluations are also performed. Neurobiological studies have demonstrated that
somatic symptoms are associated with brain dysfunction that is also responsible for
depression. Psychological pain and emotional pain have been shown to cause activa-
tion of the same sites as physical pain stimuli on MR investigations.
Evaluation of the stress axis. The documentation of neuroendocrine abnormal-
ities in cases of depression and pain have revealed the parallel course of the func-
tional changes in depression and pain and the hypothalamus-hypophysis-adrenal
axis with excess production of corticotropin-releasing hormone (CRH). It is also
known that a deficiency in the serotonin and norepinephrine monoamines can play
an important role in the decreased inhibition of pain pathways and the development
of somatic symptoms in depression [50, 51].
Comorbid symptoms. Masked depression can have various symptoms.
Urogenital system symptoms include dysuria, painful urination and defecation,
signs of urinary and fecal incontinence, functional prostate problems (prostatitis),
and bladder dysfunction in women without additional genital muscle weakness.
There may also be upper abdominal discomfort, bloating, colic-like abdominal
discomfort, stomach pain, and constipation [51].
Weakened immune system. Negative emotions such as fear and anger perma-
nently weaken our immune system and defense. The risk of catching infections such
as influenza increases many times, and wounds heal slower and in a worse manner.
Sleep disorders. Sleep problems are common when pain is present. Lack of
sleep affects both the social life and performance of the patient. Fatigue can lead
to depression and accidents. Sleep disorders have various signs such as difficulty
falling asleep, waking up frequently and quickly, long period of staying awake
during the night, being irritable, superficial sleep, loud and irregular snoring, leg
restlessness, waking up early in the morning, and disturbing thoughts. Anger and
hopelessness can also have a strong effect on sleep disorders.
It has recently been found that our brain is active in a very special manner
during sleep. The brain sends impulses, produces active substances, and is involved
in coding and storing data 24 h a day with its 100 billion nerve cells, and it is the
organ that benefits most from a good night’s sleep. This has been demonstrated with
decreased brain capacity when we get little sleep. The first sign of cerebral fatigue is
difficulty with concentrating and performing coordinated tasks such as driving or
tasks that require a great deal of attention. We then become irritated and feel pain
because of the related fatigue.
Sleep apnea. Snoring during sleep is present in 10–30% of adults and it is usually
not dangerous. However, pauses in respiration during sleep are an indicator of sleep
apnea syndrome, which affects approximately 3 million people in Germany alone.
The most common type of the disorder is “obstructive sleep apnea.” The pharyngeal
muscles relax excessively and do not let air pass, leading to a pause in the respiration
during sleep. This breathing problem goes on for about 2 min, usually with explo-
sive snoring, and the subject then starts to breath normally again. In severe cases,
these periods of paused respiration can recur hundreds of times every night. These
patients are usually prone to falling asleep during the day, and the muscles can be
weak and painful.

11
Effects of Stress on Human Health

The most important diagnostic step in the diagnosis of sleep apnea syndrome
is talking to the patient and family. In case of increased sleep apnea suspicion, the
next step is a sleep laboratory investigation. Electrodes record the ECG, blood pres-
sure, and brain waves; observe movements of the eyes and legs; measure the oxygen
content of the blood; and record each snoring and breathing sound during this test.
Lungs: shortness of breath. Our breathing becomes quite shallow in case of stress,
depression, or sadness. The lungs receive less oxygen and can provide less oxygen to the
blood, increasing the risk of infection. Pneumonia is five times more common in the
elderly than in healthy subjects.
Coronary heart disease and somatization disorder. Somatization disorder and
pain syndromes develop after a heart attack in approximately 30% of all patients. A
heart attack is experienced as a “spontaneous infarction.” Physician appointments
are frequently avoided and the recommended medication is not used. This increases
the risk of new infarction development two to four times when added to the biologi-
cal changes in the metabolism.
The infarction risk is increased several times (deaths due to a heart attack are
four to five times more common in depression patients). The more severe the
somatization disorders, the worse the prognosis of a heart disorder. Factors such as
emotional stress, dissatisfaction with work and the partner, anxiety, and long-term
stress increase the heart attack risk more than classical risk factors such as smoking
and high blood pressure.
Hair problems. The reason for white hair is mineral deficiency in the hair and
scalp, and there can be several causes: decreased nutrition due to age, acidity or
nutritional disorder, and psychological reasons. Mineral intake is decreased with
fear or stress, resulting in hair loss or white hair.
Skin disorders and skin structure problems. The metabolism slows down and
the body functions deteriorate during stress. Free radicals that attack the skin cells and
slow down the regeneration of the natural protective layer are created. The skin ages
faster and spots develop. The face appears stressed.
Gastric disorders. Gastric absorption becomes difficult in patients with
repressed emotions, anger, or anxiety. The stomach becomes tense with stress and
anger, leading to increased gastric acid secretion. This in turn causes heartburn
and can result in gastric ulcer, bloating, nausea, and cramps. Many subjects suffer
from irritable stomach or irritable colon. Psychological components also play a role.
Excitement and anxiety increase irritable stomach or irritable colon symptoms.

15. Examples of psychosomatic comorbidity in orthopedics

It is very important to investigate the relationship of psychosomatic pain in

many patients admitted between orthopedics and traumatology clinics. In this
context;
Osteoarthritis (arthrosis). Depression leads to a long period of internal stress
and increased muscle tension, causing a predisposition to motility disorders,
immobility, and arthritis. The patient usually sees an orthopedist before going to a
neurologist.
Fractures and depression. Patients suffering from depression for a long time
can be exposed to fractures more commonly as the mineral content of bone is
decreased. Heavy psychological burdens can significantly decrease the blood
oxygen content in the elderly as the breathing becomes superficial. The cells cannot
receive adequate nutrition and renewal deteriorates. Inflammation and arthritis can
develop in the joints.

12
Psychosomatic Pain
DOI: http://dx.doi.org/10.5772/intechopen.91328

Orthopedic pain syndromes. Orthopedic surgeons believe that back pain is the
result of emotional problems, not organic ones, in most cases. If job dissatisfaction
is high, the person feels overwhelmed and does not seek solutions to change the cir-
cumstances, leading to a high risk of pain as the spinal system reacts very strongly
to mental stress.
Neuropathic pain. Approximately 6% of Germans are affected by neuropathic
pain. At least 20% of the patients at pain centers suffer from neuropathic pain
syndromes. Peripheral neuropathies can commonly develop after postherpetic
neuralgia or trauma. Generalized neuropathies include those due to chemotherapy
and diabetic neuropathies.
Nociceptor pain. Nociception is the perception of pain. The responsible
receptors are called nociceptors. Nociceptors are present in all the pain-sensitive
tissues of the body as the free nerve ends of sensitive neurons of the spinal cord.
Nociceptors trigger various types of pain according to their localizations:

• Surface pain is perceived superficially by the skin nociceptors. The pain can be
clearly localized to the damaged region.

• Severe pain can be muscle pain or bone pain (localized in the periosteum)
according to the localization of the nociceptors. It is poorly localized as deep
pain due to the different fiber characteristics and the various projection areas
of pain fibers.

• Internal organ pain develops following stimulation of nociceptive receptors

in the internal organs. Classic examples are renal or biliary colic due to smooth
muscle stretching.

Myofascial pain. Myofascial pain has local causes. Individual muscles are
affected more intensely by chronic pain than muscle groups. Individual muscles
contain trigger points that signify very sensitive areas. Overloading of the muscle
can prevent excess calcium intake and the related muscle relaxation and therefore
create localized oxygen deprivation.
Long-term contraction treatment becomes difficult in the case of myofascial
pain. The sensitivity leads to the corresponding areas creating a perception of pain
even with mild contact, and these areas are therefore called trigger points.
Excessive stress on such muscles can be the result of muscle damage, inadequate
nutrition, hormonal imbalances, immobility, muscle weakness, hypothermia,
contractions, and neurological damage.
Myofascial pain mainly develops in the facial muscles, the neck muscles, the
shoulder, and the pelvis region. The trigger points can be activated spontaneously
or with light pressure to make the diagnosis [61].
Psychotherapy in the treatment of pain can be explained as follows:
Patients with psychosomatic pain may have had a very disturbing experience in
the past. This event can create links with the memory and senses, and the traumatic
disorder may occur at any time when the present experience is once again domi-
nant. Psychological stress may also cause physical illnesses. Within the soul-soma-
soul sequence, an ever-growing chain of causes can be present. Life-threatening
diseases such as cancer or myocardial infarction and the relevant medical interven-
tions can also lead to mental trauma.
Traumas, undesirable social experiences, accidents, or stressful experiences
have been scientifically proven to be the most common triggers and the causes
of many physical disorders, pain, and other illnesses without a physical cause.

13
Effects of Stress on Human Health

Changes related to psychological trauma in the brain can now be scientifically

demonstrated by imaging (such as fMRI, a magnetic resonance method) and
other diagnostic methods. Brain structure and brain metabolism are altered by the
corresponding changes in the autonomic nervous system during the stress process.
The entire spectrum of mental trauma should be considered. Psychotherapy for
psychosomatic pain due to trauma is performed in three stages and with multiple
sessions.
There are some fundamental differences between type I and type II trauma.
Type I trauma is a one-time event such as a traffic accident. The result is a
short-term mental balance disorder such as adaptation disorder or posttraumatic
stress disorder (PTSD). The patient will not forget the accident and will, for exam-
ple, be afraid of driving. However, the disorder is also accompanied by physical
symptoms (sweating, palpitation, sleep disorders, etc.).
Recurrent trauma (type II trauma) can lead to complicated disorders from all
types of neurosis to emotional disorders, anxiety disorders, and phobias, in addition
to personality disorders and changes or dependence on psychotropic drugs. Type
II trauma can develop after life-threatening disorders such as cancer or myocardial
infarction or as a result of chronic diseases. Intensive or long-term medical treat-
ment can lead to helplessness in patients with psychosomatic pain.
The results of type II trauma include the consequences of childhood and long-
term adult violence. This violence can also be mental as seen with coldness, extreme
violence and indifference, emotional wounds, and frequently repeated trauma,
especially in childhood. Type II traumas can lead to complex symptoms as in
borderline disorder with comorbidities.
A three-stage model is used for the treatment of disorders that are psychoso-
matic or accompanied by pain. These stages consist of stabilization, confronta-
tion, and integration.
It is not mandatory to include each stage in every treatment process. Stabilization
is the foundation of all treatment steps. It can be integrated into other therapeutic
methods such as specific interventions for trauma, behavioral therapy, systemic
treatment, or deep psychology-associated therapies.
Stabilization stage. Sufficient time is allocated to get to know the patient and to
create the basis of trauma therapy while building a mutually trusting relationship.
The stabilization stage creates a foundation for a common understanding of the
clinical picture. An objective viewpoint is obtained about the emotions as much
as possible. Anxiety and depression are responses to psychologically disturbing
experiences and the emotional dissociations within the patient or those around
him/her. An emergency state plan is developed together with the patient at this
stage. Relaxation techniques such as meditation or Jacobson’s progressive muscle
relaxation are then used as guides for self-passivation techniques, and the patient
thus learns the relevant methods to use the powers of healing within.
Confrontation stage. Behavioral therapy for the confrontation state has been
specifically designed to treat phobias and anxiety. Cognitive behavioral therapy and
especially systematic desensitization techniques are used. The aim is to re-evaluate
the traumatizing event.
Special therapeutic procedures for trauma are also used such as eye movement
desensitization and reprocessing (EMDR), imagery rescripting and reprocessing
therapy (IRRT), and psychodynamic imaginative trauma therapy (PITT).
Eye movement desensitization and reprocessing has been developed by the
American psychologist Francine Shapiro (* 1948). The literary translation indicates
“eye movement, desensitization and reprocessing.” This method is not hypnosis.
When the patient focuses on an especially stressful stage of the emotionally

14
Psychosomatic Pain
DOI: http://dx.doi.org/10.5772/intechopen.91328

traumatic experience, the therapist slowly asks the patient to perform rhythmic
eye movements by slowly moving his fingers and gives the patient confidence. This
stimulates cerebral processes. The aim is to decrease and even eliminate the fears
produced by the memories. More than 20 controlled studies have shown the long-
term effect of EMDR. EMDR is also included in guidelines as a preferred procedure.
Imagery rescripting and reprocessing therapy has been developed by the
American clinical psychologist Mervin Smucker (* 1949). A traumatizing experi-
ence is created together with the therapies as though it had happened today. The
patient imagines how he dealt with it in the past and how he is dealing with it now.
The patients no longer view themselves as helpless victims and feel they are the
designers of the condition who can act and maintain control even in the most diffi-
cult situations. We can think about it as deleting an old text and then writing over it.
Psychodynamic imaginative trauma therapy has been developed by psychoana-
lyst Luise Reddemann (* 1943). PITT is based on the idea that people have self-
regulating powers to cope with disturbing events even after terrible experiences.
Establishing a supportive therapeutic relationship is very important for such self-
understanding, and it is also important for helping oneself. At the heart of PITT’s
therapeutic approach is the “internal phase” that the person is currently acting on.
In this mental “imaginary” game, the patient confronts the previous ego states
with the therapist’s support. Understanding the multiple egos in the consciousness
comes from a scientific and philosophical tradition that has been present in all cul-
tures for a thousand years, and the treatment relies on a systemic approach to therapy.
With PITT, you can experience the injustice you have experienced and the area
where you feel helpless from a safe distance. The patient learns to accept this part of
his personality and to relax and make others relax at the same time. The patient also
learns to heal his/her emotional wounds and therefore regains his/her confidence.
Symbol work: the study of symbols has been developed by psychotherapist
Maria-Elisabeth Wollschläger and theologian Gerhard Wollschläger in the 1970s.
If you associate a certain feeling with an object such as a chair, a doll, or something
else, that item becomes the symbol of your senses. Symbol work is used in places
where the traumatizing event can leave you speechless and where you cannot find
the words to describe your mental wounds, what happened to you, and your anger,
grief, or helplessness. By transferring your emotions to objects or using the object
to present them, you can activate the brain areas responsible for mental processing.
Conditions of loss, for example, can increase a person’s confidence in his/her abili-
ties. You regain your ability to move and to understand that what you are doing has a
meaning, enabling further progress (self-efficacy).
Integration stage. This is the moment the joy of living and the relevant control
are regained and understood.
The aim of this stage is to gradually integrate the traumatic experiences of the
patient into his/her consciousness. These events are parts of the person’s life, and
control over life and social integration can be achieved once again by confronting
these events [4, 61–64].

16. Conclusion

Our understanding of the epidemiology of psychosomatic pain is limited to a

small number of studies that provide estimates of the prevalence in the general
population. These studies are usually difficult and costly to conduct and require
very large samples. The way data is collected and reported may also have an impact
on the estimates with various results obtained from studies that depend on surveys,

15
Effects of Stress on Human Health

interviews, or clinical investigations. Large-scale population-based studies can

provide richer data related to the age and gender distribution of pain, and assess-
ments over extended periods of time can provide comprehensive information about
the incidence and risk factors. Epidemiological studies in various cultural, social,
and ethnic groups can clarify the effects and also the interactions between the indi-
vidual and population-based risk factors. Physicians should be able to understand
the information related to psychosomatic pain, search the relevant information
available, and perform research on the subject themselves.

“The biggest misconception of today is the separation of the mind and body by
physicians.” - Socrates

“What influences us is not the events themselves but the meanings we assign to
them.” - Epictetus

Author details

Ertuğrul Allahverdi
Department of Orthopedics and Traumatology, School of Medicine, Kafkas
University, Kars, Turkey

*Address all correspondence to: ertugrulallahverdi@hotmail.com

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms
of the Creative Commons Attribution License (http://creativecommons.org/licenses/
by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

16
Psychosomatic Pain
DOI: http://dx.doi.org/10.5772/intechopen.91328
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